After a four-month Pentagon review of the military health care system, there’s good news and bad news. The study didn’t find any glaring problems, but it also concluded that a system that military officials like to think of as “excellent” actually isn’t much better or worse than private sector health care.
Defense Secretary Chuck Hagel ordered the review this summer, just as problems with access to care began to surface within the Department of Veterans Affairs. It found that there are no DoD medical facilities with alarming statistics about quality of care or waiting times. There are also no particular weaknesses in any category of care that span the entire Military Health System.
But the examination also found that the military treatment network of 50 hospitals and 600 clinics looks a lot like the U.S. medical system as a whole: Its ability to coordinate policy and share information is lacking, and the care it delivers includes a few pockets of excellence, a large amount of mediocrity, and some cases in which treatment is substandard.
“The bottom line finding is that the military health care system provides health care that is comparable in access, quality and safety to average private sector health care. But we cannot accept average,” Hagel told reporters Wednesday. “We must hold the entire Military Health System to the same exacting standards that we demand of our combat missions. I’m directing the Department of Defense to take steps to ensure that the entire Military Health Care system is not merely an average system, but a leading system.”
The review produced nearly 500 pages of detailed data on every military treatment center, based on 178 metrics the review team used to assess each facility and the system as a whole. Officials said they did not identify any systemic issues or facilities that were performing poorly across-the-board, but the data did allow them to point to certain problem areas within local treatment sites.
On Wednesday, Hagel signed a memo that orders the leaders of each of those facilities to draw up corrective action plans within 45 days for any deficiencies the reviewers found.
Among other changes, the memo also orders a one-year study of how the department can measure the performance of the private sector care DoD’s beneficiaries get through the TRICARE system.
The review team noted that the TRICARE system is a massive blind spot for the department when it comes to measuring quality of care and access to care.
Getting that data won’t be easy, because it involves a massive network of private doctors and hospitals across the country. DoD sends its beneficiaries to those providers via long-term contracts with three vendors who operate the TRICARE system in a structure that closely resembles an HMO.
But Dr. Jonathan Woodson, the assistant secretary of Defense for health affairs, said gaining access to more performance data from those private providers is vital, since the department is looking for a comprehensive assessment of how well its overall system is performing.
“We have to move the American health care system along to produce the data that we need to define the quality of care that is delivered, and this is going to be a major focus of our effort to produce contracts that require the delivery of information that allows us to give us information on quality of care that’s delivered in the purchased-care sector,” he said.
But DoD’s review also found major gaps in the department’s ability to conduct ongoing quality assessments within the facilities DoD owns and operates, itself.
New EHR will not solve all problems
While the Army, Air Force and Navy surgeons general are swimming in data about the performance of their own facilities, they each measure the metrics that affect patient outcomes and wait times in different ways, and there are very few datasets that look across the Military Health System as a whole and help guide future decisions.
Woodson said the introduction of a new electronic health record across the military services will help matters, but won’t entirely solve the problem.
“It certainly will enhance our ability to track data, and we’re looking forward to the implementation of the new EHR,” he said. “But it’s also about building the system so that you can mine the data sets, derive the information you need and produce the actionable items that you need to work on.”
Officials said on Wednesday that the new review is the beginning of a process to improve the Military Health System, and not the end.
There is much more data to collect and deconflict, including a mismatch between what patients said in surveys about their own experiences in accessing care and DoD’s measures of whether its medical centers are meeting the department’s self-imposed standards for waiting times.
For example, the review showed patients are waiting an average of 12.8 days for appointments with specialty care providers, according to medical facility data — well within DoD’s own standard of 28 days. But patient surveys show a widespread sense that military members and their families are having trouble getting appointments.
“We have heard back that our data is not actually reflecting what our beneficiaries perceive,” said Robert Work, the deputy secretary of Defense. “We are going to dive into this, and the veterans service organizations and military service organizations are going to work with us on this over the next 45 days. There’s also a difference between purchased care and the care we provide within military treatment facilities. So on the access side, we’re a little cautious right now because we want to see whether the data is telling us what is really happening. And we’re going to ask for a wide variety of different sources to help our feedback.”
This month marks the one-year anniversary of the new Defense Health Agency, an organization Congress ordered DoD to create in order to begin to knit together the military services’ three stovepiped medical organizations. DHA’s mission, so far, has been focused on consolidating the duplicative activities the three military departments had been performing on their own.
But Lt. Gen. Thomas Travis, the Air Force’s surgeon general, said the new report makes clear that the military departments need to go beyond just agreeing to use a collection of shared services for their individual health care operations.
“I think what we owe to everybody who serves in this military is a system,” Travis said. “That means that despite the fact that we provide different support for our various services — for very important reasons — as a health care system with beneficiaries and staff flowing between services, I think we need a more standardized approach, and to act like a system. I think the report helps us do that.”